Management of vitiligo

Vitiligo can begin at any age, but starts before the age of 20 years in 50% of cases. It is usually slowly progressive, but intervals of months or years may elapse when the disease is static. At other times, vitiligo may progress rapidly. Most adult cases show a symmetrical pattern but segmental involvement can be seen, especially when vitiligo starts in childhood. A history of precipitation of the disease by severe sunburn or stress is found in 20% of cases. Vitiligo is often first noticed as pale macules on sunexposed sites of the face or dorsal aspects of the hands. The distribution is usually symmetrical (Fig. 1), and may show a periorificial pattern. Another pattern is unilateral or segmental vitiligo, sometimes in a dermatomal distribution (Fig. 2). Patients with an early age of onset have less likelihood of associated autoimmune disease of other organs. Pigment loss may be partial, complete or mixed in the same areas, so-called trichrome vitiligo. Hairs within patches of vitiligo often remain pigmented, but in older lesions the hairs also become amelanotic. Some patients with vitiligo also have halo naevi (Fig. 3). From 10 to 20% of patients experience some spontaneous repigmentation, usually in sun-exposed areas, or in a perifollicular distribution. Trauma to the skin can also result in further depigmentation, i.e. the Koebner phenomenon. Occupational vitiligo can occur too after contact with industrial chemicals such as substituted phenols. Sometimes it is confined to the areas of exposure, but is frequently more extensive, implying systemic exposure. Occupational vitiligo can be indistinguishable from the idiopathic variety.